Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0115, written 25 Feb 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Feb 2026 |
|---|---|
| Reference | 2026-0115 |
| Deceased | Emma Turner |
| Coroner | Sabyta Kaushal |
| Coroner area | Derby and Derbyshire |
| Category | Community health care and emergency services related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Derby City Council 2 Derbyshire County Council 1 CORONER I am Sabyta KAUSHAL, Assistant Coroner for the coroner area of Derby and Derbyshire 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 07 February 2023 I commenced an investigation into the death of Emma Irene TURNER aged 30. The investigation concluded at the end of the inquest on 06 January 2026. The conclusion of the inquest was that: Emma Irene Turner died on 29th January 2023 at her home address of 2 Betjeman Square Derby. She was profoundly disabled with quadriplegic athetoid cerebral palsy since birth. She lacked capacity. Single and multi-agency processes for discussing Emma's clinical and social care needs were not utilised regularly and in a timely way for her benefit nor were safeguarding adult referrals fully addressed. Speech and language therapists did not see Emma in person for the 11 years between her transition from child to adult services. When she had been assessed by the speech and language therapists, they advised she should only eat pureed food. There was no face to face assessment regarding her clinical needs, her social needs nor adequate welfare checks from 2019 until her death. On 29th January 2023, having eaten some cake, her airway became obstructed as a result of vomit and that sadly resulted in her death. 4 CIRCUMSTANCES OF THE DEATH Emma Irene Turner died on 29th January 2023 at her home address of 2 Betjeman Square Derby. She was profoundly disabled with quadriplegic athetoid cerebral palsy since birth. She lacked capacity. Single and multi-agency processes for discussing Emma's clinical and social care needs were not utilised regularly and in a timely way for her benefit nor were safeguarding adult referrals fully addressed. Speech and language therapists did not see Emma in person for the 11 years between her transition from child to adult services. When she had been assessed by the speech and language therapists, they advised she should only eat pureed food. There was no face to face assessment regarding her clinical needs, her social needs nor adequate welfare checks from 2019 until her death. On 29th January 2023, having eaten some cake, her airway became obstructed as a result of vomit and that sadly resulted in her death. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. CONTROLLED Regulation 28 – After Inquest Document Template Updated 30/07/2021 The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) It is clear that her family cared and supported her but at the inquest the evidence exposed important issues with information sharing between services. Her mother, her carer should have been given more support and assisted in understanding what was in Emma’s best interests. The evidence at the inquest revealed a lack of connectivity between information systems used by different agencies; that impacted on their ability to review how other professionals would intervene in Emma's care. There had been a history of non-attendance and reluctance on the part of family members to engage with services. As a result, safeguarding referrals were made in 2018 by the Day Centre she had attended and in 2019 by a social worker after her discussions with the advanced nurse practitioner at the GP surgery. Although the evidence from the GP surgery, Derby City Council and their safeguarding team confirm that since Emma's death a number of relevant changes were being made to look after patients with learning difficulties particularly where they have not been brought to multiple appointments, in so far as the contents of the present safeguarding referral form which needs to be completed by a GP for vulnerable and learning difficulties adults, that present form is not tailored to the type of concerns that a GP would raise. The safeguarding template questions ask a variety of questions that are not relevant to a GP but to other agencies e.g. care homes, the police and community mental health teams. As a result there is a risk of there being a lack of key information provided to the safeguarding teams. Thus the safeguarding team may be delayed in responding in a timely way. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by April 12, 2026. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Derby City Council The Council House Corporation Street Derby DE1 2FS Derbyshire County Council County Hall Matlock Derbyshire DE4 3AG I have also sent it to , Derby city council Adult social care legal rep who may find it useful or of interest. CONTROLLED Regulation 28 – After Inquest Document Template Updated 30/07/2021 23 I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. 9 Dated: 25/02/2026 Sabyta KAUSHAL Assistant Coroner for Derby and Derbyshire CONTROLLED Regulation 28 – After Inquest Document Template Updated 30/07/2021
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
HM ASSISTANT CORONER SABYTA
KAUSHAL
Date: 23.04.2026
Dear Madam
Re: Response Regulation 28: REPORT TO PREVENT FUTURE DEATHS
This is Derby City Council and Derbyshire County Council's response to your report made
under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28
and 29 of the Coroners (Investigations) Regulations 2013, dated 25 February 2026,
following the death of Emma Irene Turner on 29 January 2023.
On behalf of Derby City Council and Derbyshire County Council, we wish to express our
sincere condolences to Miss Turner’s family and to acknowledge the issues highlighted in
your Regulation 28 report.
Across Derby and Derbyshire there is a joined-up, partnership approach to safeguarding
adults, underpinned by a joint Safeguarding Adults Policy which operates across both the
Derby Safeguarding Adults Board and the Derbyshire Safeguarding Adults Board areas.
As part of this partnership approach, a single Safeguarding Adults Referral Form has been
developed and implemented for use across Derby City and Derbyshire County. This form
is available online for members of the public, all partner agencies and providers, including
GP practices, to use when making safeguarding referrals.
Guidance to support people with understanding safeguarding and making referrals, is
available on both Derby Safeguarding Adult Board and Derbyshire Safeguarding Adult
Board websites, and links to this guidance will be further embedded within the digital
referral forms. It is also clear within the joint policy and procedures that referrals should be
made by telephone in the first instance, as this enables a timely and robust response to
the concerns being raised.
The Safeguarding Adults Referral Form is a single document, used to refer all types of
abuse and neglect for any adult with care and support needs who may be at risk of, or
experiencing, abuse or neglect, and who is unable to protect themselves because of those
care and support needs. Because it is used by a wide range of referrers (for example,
health professionals, care providers, police, community mental health teams, voluntary
and community sector organisations, and members of the public), the form must be
sufficiently flexible to:
cover all types of abuse and neglect
be applicable to all adults with care and support needs
enable professionals and the public to provide the key information required by the
local authority to commence safeguarding adults enquiries in a timely and
proportionate way.
We recognise the concerns raised that some sections of the current template are less
directly relevant to GPs and that this may increase the risk of key clinical or contextual
information not being clearly set out and potentially delay the safeguarding team’s
response. In recognition of this, Derby City Council and Derbyshire County Council have
worked in partnership to collate feedback from partner agencies, including GPs,
specifically on the structure, content and usability of the Safeguarding Adults Referral
Form.
Using this feedback, we are co-producing a revised Safeguarding Adults Referral Form
with partners. The aim is to make the form more streamlined and effective for all referrers,
while maintaining the flexibility needed for use across different agencies and settings. The
revisions will seek to:
clarify and prioritise the information most critical for timely safeguarding
decision-making
ensure that questions are proportionate and as relevant as possible to the wide
range of referrers, including GPs
reduce unnecessary duplication and complexity for practitioners.
This work is underway and is being taken forward as a joint piece of work across Derby
and Derbyshire. The revised Safeguarding Adults Referral Form, reflecting this
co-produced approach, will be completed and implemented by the end of July 2026.
Yours faithfully
Director of Adult Social Care Services
People's Directorate
Derby City Council
The Council House
Corporation Street
Derby
DE1 2FS
Director of Adult Social Care & Health
Derbyshire County Council
County Hall
Matlock
Derbyshire
DE4 3AG
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